letters
We select the letters for these pages from the rapid
responses posted on bmj.com favouring those received
within five days of publication of the article to which they
refer. Letters are thus an early selection of rapid responses
on a particular topic. Readers should consult the website
for the full list of responses and any authors replies, which
usually arrive after our selection.
Cancer drugs and copayments
Why not adopt the blacklist
of yore?
I suppose it is inevitable that the moral and
political issue of copayment for cancer drugs
will result in an arbitrary, bureaucratic directive,
such as that offered by the unelected Lords
Finlay and Crisp,1 whose rules I summarise:
(1) The drug or device is listed as one for which
copayment is allowed.
(2) The patient should want the treatment (and
have discussed the risks, etc).
(3) The clinician should have a reasonable
belief that benefits outweigh the benefits of
other treatment.
(4) Patients who are unable to participate in
a clinical trial should be willing for their
treatment and its outcomes to be recorded
on a register and potentially available to
research.
The rules are a sham. Who decides the
first, which trumps all others? The second
seems absurd, unless doctors foist unwanted
treatments on patients. The third is precisely the
rational/rationing problem, and begs the whole
question. Until the National Institute for Health
and Clinical Excellence (NICE) has assessed
the evidence and ruled the drug in, only expert
specialists (and their peers) can reasonably
anticipate NICE judgmentsprecisely the
situation which NICE was invented to contain.
The last rule is high handed and authoritarian.
If I did not consent, or was otherwise unable
to participate in a clinical trial, why should I be
required to participate in records, registers, and
research? What if I were to refuse? Why is it that
NHS managers, doctors, and politicians want to
control what I do with my money in a free society?
They should limit themselves to that part which is
taken from me in tax.
The question is not new, and a working
solution has been usual NHS practice for 20
years. In 1986 the NHS decided to formally
blacklist several drugs deemed to be of
insufficiently evidenced effectiveness. The
alternative and presumably effective drugs were
later to become known as the whitelist. Patients
who insisted that Mogadon was superior to
nitrazepam were allowed to pay for it on private
prescription from the same general practitioner
who was forbidden to prescribe it on an NHS
pad. The working rules seem to be:
BMJ | 19 july 2008 | Volume 337 127
(1) The drug or device is blacklisted (not NHS
funded ).
(2) The patient should want the treatment (and
have discussed the risks, etc).
(3) The clinician should have a reasonable
belief that the prescription is safe, effective,
and legal.
(4) Patients who are unhappy are referred to
their elected MP.
L Sam Lewis general practitioner, Surgery, Newport,
Pembrokeshire SA42 0TJsam@garthnewydd.freeserve.co.uk
Competing interests: None declared.
1 Finlay I, Crisp N. Drugs for cancer and copayments. BMJ
2008;337:a527. (30 June.)
Cite this as: BMJ 2009;337:a807
Critical issue is rapidity of
review of new drugs
Baroness Finlay and Lord Crisp support
copayments with four essential criteria.1 The
fourth criterion will fail as the denominator
is described as a small group in the scale of
the NHSs customer base. There is also the
assurance that this is mostly for drugs yet to be
reviewed by the National Institute for Health and
Clinical Excellence (NICE).
That is not the experience revealed by recent
high profile cases in the media where cetuximab
for colorectal cancer has featured prominently
and it has been rejected by both NICE and the
Scottish Medicines Consortium (SMC). Finlay and
Crisp say that it is a fundamental and essential
principle that all drugs and devices fully proved
through appraisal should be available freely,
but do they support the corollary that drugs and
devices rejected by appraisal are excluded from
their approved copayment list? The authors also
compare favourably the use by patients of self
funded complementary therapies nearly all of
which have no evidence base and have never
undergone the rigours of the appraisal by NICE or
SMC. Such self-medication cannot be used as an
argument to assist one apparently small group of
patients to copay what others will be denied.
The critical issue to address is the rapidity
of NICE and SMC review, a process that is often
lengthened, not by those bodies but by the
time it takes industry to submit to them after
licence; to ensure that which is approved is made
available at no cost to the patient as soon as
possible; and to manage a fair and open system
of assessing non-formulary applications.
The next byelection to the UK parliament is in a
constituency where cancer mortality statistics are
poor. Allowing those on disability benefit or the
old age pension to copay for new cancer drugs
will make no impact on thatbecause they could
not. This debate is emotional because it affects
lives and, I suspect like 60 years ago, relates not
a little to fears over clinical freedom. It needs also
to focus on equity and fairness.
Alan Rodger medical director, Beatson West of Scotland
Cancer Centre, Glasgow G12 0YN
alan.rodger@ggc.scot.nhs.uk
Competing interests: I am required to assess all non-
formulary medicines requests for our cancer centre.
1 Finlay I, Crisp N. Drugs for cancer and copayments. BMJ
2008;337:a527. (30 June.)
Cite this as: BMJ 2008;337:a779
Darzi review
Clinical dashboards and
open kimonos
My admission: in a previous life, I was a
designer of emperors clothes. I worked
in corporate venturing and management
consultancy for seven years. In short, I know a
bit about dashboards. So, when I read that Lord
Darzi was championing them in hospital foyers,1
I felt moved to write.
Clinical dashboards arent a new idea.
Googlesearch and youll get over a million
results. In fact, the NHS has already met the
dashboard. The top 10 results reveal that Barts
and the Royal College of Obstetricians and
Gynaecologists use them. Why?
Its an attractive tool which claims to bring
simplicity to the complexity of running a large
organisation. The root analogy is of a ships
bridge. The captain can see, at a glance, where
hes going, how fast, how efficiently, and where
the icebergs might be.
There are two problems.
 letters
Firstly, the targets youre measuring against are
set at a moment in time and are either extremely
conservative (set by managers who know theyll
be judged on them) or super-ambitious (set by
managers to show they are a thrusting team).
Secondly, a Kentuckian management
consultant once told me, if you open your
kimono, you better have something worth
showing. Same with the dashboard. Its natural
history is to arrive to a large fanfare, work, work
too well, be fudged, then be withdrawn. Why?
The easy stuff gets done, the difficult things
dont. Excuses are followed by the realisation
that some of the targets are unachievable, even
undesirable.
Cynicism aside, the dashboard is a useful tool.
I have one now telling me how behind I am with
my finals revision. But, who is it useful for? The
captain of the ship, not the passengers. A public
dashboard is doomed to failure. The complexity
beneath it needs a depth of understanding
and an ability to change course and do whats
necessary to keep the ship moving.
So, a message to Lord Darzi, please sir, keep
your kimono closed.
Neil J Hughes third year medical student, St Georges
University of London, London SW17 0RE
m0402783@sgul.ac.uk
Competing interests: None declared.
1 Kmietowicz Z. Darzi review: Annual quality accounts
will help improve services and increase choice for
patients, says Lord Darzi. BMJ 2008;337:a646. (3 July.)
Cite this as: BMJ 2008;337:a787
NHS at 60
Doctors infantalisation
I have been both manager and doctor in the
intensive command and control regime of
national targets, inspection and regulation, and
published league tables of our 60 year old NHS.1
My performance as a manager was measured on
my teams ability to deliver government efficiency
targets, with original thinking commonly stifled.
My performance as a junior doctor is assessed
on the ability to deliver these targets alongside
individual, high quality, evidence based care.
My audit at a foundation trust showed how
trust policy actively ignores clinical guidelines
to achieve performance indicators. This
exposes patients to unnecessary admission
and investigations, and prevents junior clinical
staff from seeing, learning, and practising
good clinical medicine. Junior doctors and their
patients have less power than administrative
staff and managers chasing after a performance
indicator turning red.
Whereas patients now have choice into the
who and where of treatment, clinicians grumble
they have less choice in how to deliver this. I now
have to write up my assessment of a patient on
a standard proforma, although the same sized
128 BMJ | 19 july 2008 | Volume 337
box obviously does not fit every patient. Through
standardisation the nuances of a consultation,
the backbone of individual care, are lost. But so
are my opportunities to use my ability to think, a
skill crafted at universityin my case on behalf
of my patient. The proformas symbolise the
creation of a monochromatic, uniform NHS and
workforce, which of course negates the need for
patients to choose who and where.
The mindsets of my generation of clinicians
will lead the NHS at its centenary birthday. Then
we may well be desperate for a new policy toy or
proforma to implement. Because, unless Daddy
tells us, how will we know how to think and what
to do? Our patients with their powers to choose
and assess performance will be more grown up
than the children inside but leading the NHS.
Alexandra Thomson-Moore foundation doctor,
West Suffolk Hospital, Bury St Edmunds, Suffolk IP33 2QZ
1977atm@doctors.org.uk
Competing interests: None declared.
1 Delamothe T. A fairly happy birthday. BMJ
2008;337:a524. (30 June.)
Cite this as: BMJ 2008;337:a791
Media and health service
How the government is
failing the health service
Snows article is a refreshing reminder that most
of the NHS works very well.1 But its not just the
media that concentrate on the rare instances of
poor practice to make sensational claims that sell
their papers: the government does exactly the
same, apparently to turn our patients against us
and support their political reforms.
A good example comes from the governments
own 23m survey showing that 84% of patients
are content with their general practitioners
opening hours; its response (presumably
premeditated) is to beat us over the head with the
other 16% and impose extended opening hours.
An insight into the governments philosophy
was provided by its health minister in national
news broadcasts on 3 July. Ben Bradshaw
announced that gentlemens agreements operate
that mitigate against lists being open to new
patients and therefore work against real patient
choice. Bradshaw was forced to climb down by
balanced journalism on the BBC Radio 4 Any
Questions programme on 4 July. The transcript I
compiled is illuminating:
Jonathan Dimbleby (chair):
When you say that they have this
gentlemans agreement to undermine
patient choice, what are you claiming that
they are doing? ...
Ben Bradshaw (health minister):
In a very small number of places in the
country people tell us that when they try
to change their GP theyre told by their GP
practice, No you cant because we ... will
not take patients from other practices.
Its... certainly not the biggest obstacle to
patient choice, which is one of the things
that we want to try to encourage; there are far
bigger obstacles to patient choice, but I have
to say... we were inundated by emails and
calls from people who had
JD: [interrupting]: What does inundated
mean?
BB: I had more emails than Ive ever had on any
other issue from members of the public
JD: Is that 10 or a hundred or a thousand? Ten
thousand?
BB: No, to my parliamentary office its more than
10, which I can tell you is a lot.
JD: More than 10.
BB: A lot. [Laughter from audience]
JD: With respect, is more than 10 enough to
use people tell us [as] evidence to make
a statement which has so outraged the
BMAnamely, that theyre operating a
gentlemans agreement? ... Isnt that sort of
pushing it a bit?
BB: Its enough to indicate to me that the claim
by the BMA leadership ... that this never
happens is not true.
Its pretty demoralising for us to witness such
prejudice in our policymakers, knowing that this
attitude is fed down to the primary care trusts.
Now the cat is officially out of the bag I hope they
will understand any reluctance we may have to
believe what they say and cooperate with their
reforms.
Richard A D OBrien general practitioner principal, East Quay
Medical Centre, Bridgwater, Somerset TA6 4GP
RichardAOB@aol.com
Competing interests: RADOB is a hard working general
practitioner.
1 Snow J. How the media are failing the health service.
BMJ 2008;337:a572. (30 June.)
Cite this as: BMJ 2008;337:a784
Key opinion leaders
Thus are our medical
meetings managed
Outraged key opinion leaders will undoubtedly
protest that their opinions are unaffected by
industry honorariums and hospitality.1 In some
cases this is true. According to an anonymous

industry insider interviewed by a publicly funded
project I direct (PharmedOut.org), academic
physicians are tracked by industry from early in
their careers. Promising young faculty are invited
to one on one meetings by pharmaceutical
company executives, who interview them about
their work and opinions over an expensive
meal with excellent wine. Each potential recruit
is flattered and well fed. However, only those
whose opinions align with marketing messages
are taken under a companys wing, to be
financially supported, pampered, and admired
while being flown around to speak at academic
medical centres and medical conferences.
Some key opinion leaders are genuinely
unaware of the marketing message they are
disseminating. A key opinion leaders opinion
that a certain disease is underdiagnosed,
undertreated, or more serious than commonly
believed can align perfectly with a companys
marketing goals even if drugs are never
mentioned. Pharmaceutical companies seek long
term relationships with the key opinion leaders
whom they recruitor create. Constant support,
treats, and the gentlest of suggestions by ones
friends ensure the continued alignment
of a key opinion leaders statements with a
companys marketing messages. It is absolutely
essential to maintain the illusion of the key
opinion leaders independence and integrity.
Most experts are some companys key
opinion leaders. Thus are our medical meetings
managed to limit discourse to competing
profitable therapies, and to overwhelm non-
industry funded voices.
Adriane Fugh-Berman associate professor, Georgetown
University Medical Center, Washington DC, 20057, USA
ajf29@georgetown.edu
Competing interests: The author has been a paid expert
witness on the plaintiffs side in litigation regarding
pharmaceutical marketing practices.
1 Moynihan R. Key opinion leaders: independent
experts or drug representatives in disguise? BMJ
2008;336:1402-3. (21 June.)
Cite this as: BMJ 2008;337:a789
Getting them while theyre
young
Having read Moynihans piece about key
opinion leaders,1 we would like to describe
another communication platform that the
drug industry uses to influence the prescribing
habits of doctors.
Although it is not strictly a condition of
employment, many deaneries promote doctors.
net.uk and request that medical students and
foundation programme doctors open email
accounts with the company. Accounts allow
access to forums where doctors can discuss
cases, resources including the Oxford Textbook
of Medicine, and CPD accredited online
BMJ | 19 july 2008 | Volume 337 129
educational modules. But should deaneries be
promoting this service?
The company claims to be run by doctors and
for doctors. However, its chief executive officer,
Richard Adams, began his career as a medical
representative for Wellcome, and operations
director Paul Concannon has 22 years
experience in the drug industry. The company
receives funding from drug companies that in
return market their products to a selection of the
services subscribers.
The website describes their marketing
methods (see doctors.net.uk/marketing).
One campaign to increase the depth of
prescribing used a key opinion leader webcast.
Another delivered 3500 accredited disease
education modules to doctors. Colourful
graphics demonstrate the effects their
marketing campaigns have on knowledge,
prescribing, and prescribing intentions.
Data needed to establish the size of the
effect that online marketing has on prescribing
practices are not freely available. Nevertheless,
drug companies and doctors.net.uk apparently
find this to be a profitable investment.
Deaneries are charged with turning graduates
into competent doctors who prescribe drugs
rationally on the basis of objective evidence.
It is therefore highly regrettable that they are
encouraging medical students and doctors to
have drug company sponsored email addresses.
Carl J Reynolds foundation programme year 1 doctor,
Basildon Hospital, Basildon SS16 5NL
zchaxy6@ucl.ac.uk
Tom Yates medical student, Royal Free and University
College Medical
Robert Hughesfoundation programme year 1 doctor,
Whipps Cross University Hospital, London E11 1NR
Competing interests: None declared.
1 Moynihan R. Key opinion leaders: independent
experts or drug representatives in disguise? BMJ
2008;336:1402-3. (21 June.)
Cite this as: BMJ 2008;337:a792
How it really works
Buckwell pleads for an idealised state of
transparent relations between the industry and
key opinion leaders.1 The reality is different.
Here is a description from an internationally
recognised clinical scientist about his
letters
experience with the industry. I respect his
confidentiality and that of the corporation. My
colleagues experience is not atypical.
When [the company] first began trumpeting
the success of [their drug], I was asked to be
on their speakers bureau. In a large audience
... I departed from the script I was given for the
published data to note that the effect size
was significantly lower than the [alternative
treatments]. Since most [of the audience] had
no idea what effect size is, I gave a brief
explanation. That evening I received a phone call
in my hotel room from [the companys] director
of the program. He chastised me for being off
message and warned me not to make these
intrusive statements. I told him that I did not
work for [the company], and that presumably
I was asked to give these talks because I was
a respected researcher in the field and had
participated in some of the early trials of their
drug, including meetings to develop a protocol
for their FDA submissions. I repeated my
performance the next day, and was never asked
to talk for them again.
Over the years I have given many talks
sponsored by corporations, but I gave my talk,
using my slides, and choosing my topic. These
presentations were designed for educational
impact, and the companys drugs were never
the central focus. They were extremely popular.
About five years ago I was informed that
henceforth I must use the companys topics and
slides, with no deviations allowed. The corporate
material provided was mediocre in quality and
infomercial in tone. That is when I stopped giving
company-sponsored lectures in the US.
Bernard J Carroll consultant, Pacific Behavioral Research
Foundation, PO Box 223040, Carmel, CA 93922-3040, USA
bcarroll@redshift.com
Competing interests: None declared.
1 Buckwell C. Should the drug industry work with key
opinion leaders? Yes. BMJ 2008; 336: 1404. (21 June.)
Cite this as: BMJ 2008;337:a788
How to spot one
The key opinion leader may be an independent
expert or a drug company representative
in disguise, but not both at once.1 The drug
company representative in disguise is easy
to spot. His expenses and remunerations are
shamelessly high and he uses proprietary names
and drug company slides. Sometimes he praises
a mediocre drug to the skies. He is engaged
for multiple appearances and is referred to by
colleagues as a traveller for a drug company.
Fortunately, I believe that the independent
expert is more likely to be hearkened to than the
drug rep in disguise.
Alexander S D Spiers professor of medicine (retired),
Cookham Dean, Berkshire spiersuk@thamesinternet.com
Competing interests: None declared.
 letters
1 Moynihan R. Key opinion leaders: independent
experts or drug representatives in disguise? BMJ
2008;336:1402-3. (21 June.)
Cite this as: BMJ 2008;337:a790
High tech gadgetry introduced
by stealth
Key opinion leaders also promote technical
devices developed for minimally invasive surgical
approaches.1 Clinicians are offered training and
mentoring by an expert on condition that they
guarantee advance purchase of a substantial
number of interventional procedures by their
trust or commissioning body. In national priority
areas such as cancer and cardiology some
commissioners accede to persistent clinical
demands, even though the devices may be at an
early stage of their development. Purpose built
suites and infrastructure may also need to be
provided.
By their acquiescence, a few commissioners
inadvertently exert indirect pressure on their
colleagues elsewhere. Clinicians and trusts are
anxious not to lag behind in the race for the
latest technological advance, but the casualty
is an evidence based, clinically and cost
effective commissioning strategy underpinned
by an objective critique of the limited evidence.
Commissioners are left to pursue rearguard
damage limitation by constructing retrospective
clinical governance controls.
The losers are patients at the receiving end
of an intervention that lacks an evidence base.
Medical science also loses because if phase
three trials are ever done, they will report so late
that their results are meaningless because the
technological goalposts will have shifted by then.
Commissioners must stand firm and agree
only to well researched interventions backed
up by health economic evaluation. Proposers of
new clinical developments must declare conflicts
of interest and financial links with the industry
at the outset. Acute trusts and commissioners
should make it a condition of releasing doctors
from service provision for training programmes
that the training fits with agreed commissioned
service developments. To do otherwise
jeopardises the many other patients whose
conditions are not interesting, are not amenable
to treatment with high profit drugs, or do not
require the use of high tech gadgetry.
Su Sethi consultant in public health medicine, North West
Specialised Services Commissioning Team, Quayside,
Warrington WA4 6HL su.sethi@northwest.nhs.uk
Claire ODonnell clinical effectiveness in public health, North
West Specialised Services Commissioning Team, Quayside,
Warrington WA4 6HL
Competing interests: None declared.
1 Moynihan R. Key opinion leaders: independent
experts or drug representatives in disguise? BMJ
2008;336:1402-3. (21 June.)
Cite this as: BMJ 2008;337:a782
130 BMJ | 19 july 2008 | Volume 337
A friend in need Competing interests: None declared.
1 Loxterkamp D. A friend in need: why friendship matters
General practitioners must in medicine. BMJ 2008;337:a528. (1 July.)
Cite this as: BMJ 2008;337:a798
have their own list
What a great synopsis of our work as general Manners in medicine
practitioners.1 How impossible to quantify for
any assessment. What a gap there will be should
Whats in a name?
polyclinics take over and patients see strangers, As a patient I have been quite taken aback that
oblivious to the bond that Loxterkamp extols. whenever Ive seen doctors recently they have
Like him, I am the son of a country general called me by my first name while introducing
practitioner, who practised in the era of Balint themselves by their title and surname. I find it
training. Now that I am well retired, I just wish distinctly unhelpful in my interaction with another
that I had listened more carefully and touched adult to be addressed like a child by their teacher
more often. Yet I was rewarded by that sense of when the experience of illness is already making
connection, the feeling that they were personally me feel unsettled, vulnerable, and anxious.1
known, which always left me convinced that Whenever I have raised this matter of unequal
an own list was the only way to practise. address during a consultation, it has been met
Regrettably, it is disappearing fast. with surprise and the mention of wanting to
Alexander Michael Hall-Smith retired general practitioner, make me feel at ease. In Germany it would be
Wisbech PE14 0BQ unthinkable for a doctor to introduce himself as
am.hs@virgin.net
Dr Schmidt while summoning a patient from the
Competing interests: None declared.
1 Loxterkamp D. A friend in need: why friendship matters waiting room by calling out Helmut or Angela.
in medicine. BMJ 2008;337:a528. (1 July.) I am curious as to whether there have been any
Cite this as: BMJ 2008;337:a797 recent guidelines to encourage this practice in
Britain, why it seems to be the norm, and why do
so few people question, let alone challenge, it?
Caring still lives This is occurring at the same time as there is so
The practice of friendship and compassion in much talked and written about patients dignity,
medicine is alive and well.1 Medicine is not the doctor-patient partnership, respect, and
merely a cold, competency based, clinical empowerment.
science but a warm, profound, and tactile art. Anke Medrington interpreter and translator
Proficiency at medicine cannot be measured by Stockport SK4 2QU
ankevondallau@googlemail.com
exams or research but only that most potent of
Competing interests: None declared.
barometers, patients satisfaction. We are the 1 Richards T. Manners in medicine. BMJ 2008;336:1408.
most privileged profession in society; people (21 June.)
from all walks, sexes, and colours will take their Cite this as: BMJ 2008;337:a687
time to divulge innermost hopes and fears,
but only if we take our time to reach out and Antipsychotics for dementia
listen. Patients and doctors both want to feel
valued and to be remembered, and this will be Antipsychotics for dementia is
achieved only by a mutual sharing in each others
experiences and lives. Dont blame your lack
metaphor for elderly care
of training, time, or team members, because The blunt treatment of so called behavioural
this is a skill that cannot be taught, rushed, nor and psychological symptoms of dementia
delegated. This skill is called caring. with antipsychotics is a metaphor for medical
David R Warriner F2 doctor (general practice), Derwent care of the older patient.1 Individualised care
Surgery, Malton YO17 8PH plans with a true patient focus in a supportive
environment will filter many prescriptions. The
problem very often isnt the patient but the
provider and the care setting. Our residential
MUSEE DORSAY, PARIS, FRANCE/GIRAUDON/BAL
prevalence of prescribing antipsychotics has
fallen from 36% to 20% in 18 months, thanks
to a concerted team approach to challenging
behaviours.
Paddy Quail medical director, Intercare, Holy Cross Centre,
Calgary, Alberta, Canada T2S 3C3
quail@ucalgary.ca
Competing interests: None declared.
1 OBrien J. Antipsychotics for people with dementia. BMJ
2008;337:a602. (9 July.)
Cite this as: BMJ 2008;337:a796